monograph on lung cancer - lung center of the...

MONOGRAPHON

LUNG CANCERLUNG CANCER REGISTRY DATA OF 2000–2008

Department of Research and DevelopmentLung Center of the Philippines

LUNG CENTER OF THE PHILIPPINES

iiMONOGRAPH ON LUNG CANCER: LUNG CANCER REGISTRY DATA OF 2000–2008 Lung Center of the Philippines

MONOGRAPH ON LUNG CANCERLung Cancer Registry Data of 2000–2008Copyright 2016 Lung Center of the PhilippinesAll Rights Reserved.

ISSN: 2467-6950

An electronic copy of this publication may be downloaded at lcp.gov.ph

Articles and tables may be reproduced in full or in part for non-profit purposes without prior permission, provided credit is given to the Lung Center of the Philippines.

Published annually by theLUNG CENTER OF THE PHILIPPINESDepartment of Research and DevelopmentRoom 4005, Lung Center of the PhilippinesQuezon Avenue Extension, Quezon CityPhilippinesTelefax: +63-2-924-6101 local 235E-mail: [email protected]

iiiLung Center of the Philippines MONOGRAPH ON LUNG CANCER: LUNG CANCER REGISTRY DATA OF 2000–2008

THE

REG

ISTR

Y T

EAM SULLIAN S. NAVAL, MD

Department Manager IIIDepartment of Research and DevelopmentRoom 4005, Lung Center of the PhilippinesQuezon Avenue Extension, Quezon CityPhilippines

MARIA LOURDES E. AMARILLO, MPHBiostatistician Consultant/Associate Professor 5Department of Clinical EpidemiologyUniversity of the PhilippinesRoom 103 Paz Mendoza, UP College of Medicine547 Pedro Gil Street, ErmitaManila Philippines

VINCENT M. BALANAG JR., MD, MScMedical Specialist IIDepartment of Research and DevelopmentRoom 4005, Lung Center of the PhilippinesQuezon Avenue Extension, Quezon CityPhilippines

RUTH DC. BABALO, MDMedical Officer III / Research FellowDepartment of Research and DevelopmentRoom 4005, Lung Center of the PhilippinesQuezon Avenue Extension, Quezon CityPhilippines

CORAZON ADELE F. LAVADIAStatistician IIDepartment of Research and DevelopmentRoom 4005, Lung Center of the PhilippinesQuezon Avenue Extension, Quezon CityPhilippines

To our beloved Robert, whose unobtrusive ways, simplicity andperseverance inspired us to carry on this challenging undertaking.

viiLung Center of the Philippines MONOGRAPH ON LUNG CANCER: LUNG CANCER REGISTRY DATA OF 2000–2008

The Registry Team ......................................................................................................................... iii

Table of Contents .........................................................................................................................vii

List of Appendices ........................................................................................................................ix

List of Figures ..................................................................................................................................xi

List of Tables ..................................................................................................................................xiii

Foreword ..........................................................................................................................................xv

Preface ........................................................................................................................................... xvii

Acknowledgement...................................................................................................................... xix

Introduction .......................................................................................................................................1

Objectives .........................................................................................................................................3

Methodology ....................................................................................................................................4

Results .................................................................................................................................................5

Summary .........................................................................................................................................20

Recommendations ........................................................................................................................22

References ..................................................................................................................................... 23

Appendices .................................................................................................................................... 25

TAB

LE O

F C

ON

TEN

TS

ixLung Center of the Philippines MONOGRAPH ON LUNG CANCER: LUNG CANCER REGISTRY DATA OF 2000–2008

LIST

OF

APP

END

ICES

25 Appendix 1. Lung Cancer Registry Form (LCP Form No. 62-001)

27 Appendix 2. Lung Cancer Registry (Follow-up/Re-admission Form) (LCP Form No. 62-013)

28 Appendix 3. Lung Cancer Registry (Management Form) (LCP Form No. 63-003)

xiLung Center of the Philippines MONOGRAPH ON LUNG CANCER: LUNG CANCER REGISTRY DATA OF 2000–2008

LIST

OF

FIG

UR

ES

16 Figure F1. Frequency distribution of patient’s vital status according to sex (as of December 31, 2011)

16 Figure F2. Frequency distribution of patient’s vital status according to age group (as of December 31, 2011)

17 Figure F3. Frequency distribution of patient’s vital status according to smoking status (as of December 31, 2011)

17 Figure F4. Frequency distribution of patient’s vital status according to alcohol intake status (as of December 31, 2011)

18 Figure F5. Frequency distribution of patient’s vital status according to lung cancer histopathology (as of December 31, 2011)

18 Figure F6. Frequency distribution of patient’s vital status according to lung cancer stage at notification

xiiiLung Center of the Philippines MONOGRAPH ON LUNG CANCER: LUNG CANCER REGISTRY DATA OF 2000–2008

LIST

OF

TAB

LES 5 Table A1. Frequency and percentage distribution of incident cases

according to patient’s sex and year of first hospital admission

5 Table A2. Frequency and percentage distribution of incident cases according to patient’s age and year of first hospital admission

6 Table A3. Frequency and percentage distribution of incident cases according to patient’s sex and age

6 Table A4. Frequency and percentage distribution of incident cases according to patient’s civil status and year of first hospital admission

7 Table A5. Frequency and percentage distribution of incident cases according to permanent address (region) and year of first hospital admission

8 Table A6. Frequency distribution of incident cases according to patient’s occupation and year of first hospital admission

9 Table B1. Frequency and percentage distribution of incident cases according to patient’s smoking status and year of first hospital admission

9 Table B2. Frequency and percentage distribution of incident cases according to patient’s alcohol intake and year of first hospital admission

10 Table B3. Frequency distribution of co-existing illnesses among lung cancer patients during their first hospital admission

10 Table B4. Frequency distribution of medical conditions in the patient’s family history according to year of first hospital admission

11 Table C1. Frequency and percentage distribution of incident cases according to histological classification of lung cancer and year of first hospital admission

12 Table C2. Frequency and percentage distribution of incident cases according to lung cancer stage and year of first hospital admission

13 Table D1. Frequency and percentage distribution of incident cases according to gender and histological classification of lung cancer

13 Table D2. Frequency and percentage distribution of non-small cell lung cancer cases according to sex and cell type

14 Table E1. Frequency distribution of management options availed on patient’s first admission

14 Table E2. Frequency distribution of management options availed according to histological classification of lung cancer

15 Table E3. Frequency distribution of incident cases according to lung cancer stage and management options availed on admission

19 Table F1. Life table of lung cancer patients at different time intervals for all cell types

xvLung Center of the Philippines MONOGRAPH ON LUNG CANCER: LUNG CANCER REGISTRY DATA OF 2000–2008

FOR

EWO

RD Clinical Registries are databases with systematically collected patient

data usually for a certain condition or treatment. The information contained in a clinical registry is contributed by different physicians describing a diverse group of patients in varied settings following different courses of treatment and management for the same condition. Insights can be gleaned from registries to determine the best treatment course for patients, and outcome data create benchmarks to gauge quality of care1 especially with changes in approach over time if the patient is tracked prospectively.2 In Sweden, the country which has made the most use of clinical registries since the early 1800s, health administrators and physicians harness the information from over 70 registries to provide more powerful analyses for long-term outcomes using longitudinal data that show evolving patterns of practice and outcomes.3 A good example of how registry information can lead to a change in clinical practice is the recommendation by the European Society of Cataract & Refractive Surgery to inject ofloxacin after cataract surgery to reduce the incidence of endophthalmitis.4 The Lung Cancer Registry of the Lung Center of the Philippines (LCP) aims to create such a tool for physicians involved in the treatment of lung cancer.

The beginnings of this work dates back in the early 1990’s when repeated attempts of putting up a hospital lung cancer registry began. Appropriately so, this was the initiative of the Hospital Tumor Board steered by then Director Calixto A. Zaldivar and Pulmonologist-Oncologist, Dr. Roberto Montevirgen. Even with the best efforts, the Department of Research & Development could not move forward, beset by problems of poor patient follow-up and limited manpower complement. This monograph is the first fruit of a long arduous journey towards establishing a true and fully functional lung cancer registry.

The number of admissions for lung cancer has ranked first among the pulmonary diseases seen at the Lung Center of the Philippines since 2000 (post fire statistics). This monograph covers the period 2000-2008 and accurately portrays the hospital’s in-patient lung cancer burden. Scrupulous inclusion criteria were followed and the data meticulously cleaned and validated. Having said that, this document may well be the first (locally) accurate description of lung cancer cases admitted to a tertiary hospital. The following pages detail the demographic profile, clinical characteristics, histopathologic diagnoses and management of lung cancer. Another first in this undertaking is the hospital’s

1. American Medical Association. What is Clinical Data Registry? National Quality Registry Network (2014). http://www.abms.org/media/1358/what-is-a-clinical-data-registry.pdf

2. McGirt MJ, Parker SL, Asher AL, Norvell D, Sherry N, Devin CJ. Role of prospective registries in defining the value and effectiveness of spine care. Spine (2014) 39(22 Suppl 1):S117-28.

3. Larson S, Lawyer P, Silverstein, MB. Putting value-based health care into practice in Sweden. Boston Consulting Group (2010) https://www.bcg.com/documents/file64538.pdf

4. ESCRS. Guidelines for Prevention and Treatment of Endophthalmitis Following Cataract Surgery. (2013). http://www.escrs.org/endophthalmitis/guidelines/ENGLISH.pdf

xviMONOGRAPH ON LUNG CANCER: LUNG CANCER REGISTRY DATA OF 2000–2008 Lung Center of the Philippines

collaboration with the National Statistics Office to enable a more complete follow up of the vital status of diagnosed patients. Some data on survival are shown but a more thorough dissection of this issue is the subject of another paper.

The authors recognise that data like the above should contribute ultimately to the benefit of the patient. The data clearly mandate for an early detection program that will make medical management efforts more successful. Evaluation studies on pertinent aspects of patient care from diagnosis, management and support services can be carried out from several vantage points namely, medical, economic, and administrative.

Cognisant of the immense potential of a valid lung cancer registry, the Department together with the Hospital Tumor Board seek to engage all stakeholders to make the LCP Lung Cancer Registry a stable, reliable programme.

SULLIAN S. NAVAL MD

xviiLung Center of the Philippines MONOGRAPH ON LUNG CANCER: LUNG CANCER REGISTRY DATA OF 2000–2008

PREF

AC

E The registry (or recorder) of deeds, according to Wikipedia, is a government office tasked with maintaining public records and documents, especially records relating to real estate ownership … (and) provides a single location in which records of real property rights are recorded and may be researched by interested parties.

A lung cancer registry, on the other hand, provides lung cancer numbers for age group and sex incidence, crude incidence rate, morphology, treatment and its complications and outcome, and other data deemed dull by the public at large.

The operative word is registry defined as a place where official records are kept or a book or system for keeping an official list or record of items.

The Lung Cancer Registry of the Lung Center of the Philippines is therefore a long-awaited welcome addition to the armamentarium of clinicians, researchers and even policymakers.

Information to be derived from this registry will be used to define pathways of care and their outcomes. In a data-driven world, this registry will provide quality of care for health practitioners, institutions and the national health insurance service. Furthermore, these data will provide an invaluable tool for further research in lung cancer.

Lung cancer is one of the deadliest cancers and is among the top three cancers in the Philippines. We at the Lung Center of the Philippines are committed to renew the fight against lung cancer which constitutes around 60% of its total hospital admissions. With the ongoing researches at our Molecular Diagnostics and Cellular Therapeutics Laboratory, the planned early detection of lung cancer program by the Department of Radiology and the forthcoming creation of a separate Department of Thoracic Oncology and a Genomic Medicine Unit, the addition of a lung cancer registry is indeed a timely reinforcement.

JOSE LUIS J. DANGUILAN, MD Executive Director Lung Center of the Philippines

xixLung Center of the Philippines MONOGRAPH ON LUNG CANCER: LUNG CANCER REGISTRY DATA OF 2000–2008

AC

KN

OW

LED

GEM

ENT The Department of Research and Development acknowledges the

invaluable contribution of the following partners in the development of this publication: Director Lourdes J. Hufana, Civil Registration Department of the National Statistics Office; UPLB BS Statistics students, Faye Anne Manzano, Zendie Saavedra, Kathlea de Sagun; The Lung Foundation; The LCP Hospital Tumor Board; The LCP Medical Records Section.

1Lung Center of the Philippines MONOGRAPH ON LUNG CANCER: LUNG CANCER REGISTRY DATA OF 2000–2008

INTR

OD

UC

TIO

N Lung Cancer is a condition characterized by the multiplication of abnormal cells lining the airways that grow and divide continuously to invade and cause damage to adjacent organs. Its impact on general health lies on the fact that it is a serious disease that can be treated but cure is less likely especially among those who are in advanced stages.

Identifying who among the population are more likely to develop lung cancer is challenging and still needs further analysis and research. Several risk factors associated with its evolution have been recognized in previous studies here and abroad. Smoking is by far the most common preventable risk factor associated with the development of lung malignancy as well as from other organs including the mouth, throat, esophagus, and larynx [1-2]. Personal vulnerability can be attributed to mutations of genetic inheritance [3-5]and exposure from a particular occupational or environmental carcinogen, including asbestos, indoor or ambient air pollution [6-8].

There are no universally accepted and effective screening tests for patients at risk of lung cancer. Clinical trials of screening using annual chest x-rays and/or sputum cytology have not seen any reduction in lung cancer mortality [9-11]. Recently, low-dose CT screening has been introduced but its general effectiveness has still to be confirmed by on-going randomized controlled trials [12-14].

Evaluation of a patient suspected of having cancer can be difficult owing to signs and symptoms such as cough, weight loss, fatigue, anorexia, and hemoptysis that are non-specific and indistinguishable from other respiratory illnesses [15-16].

Diagnosis of lung cancer significantly affects the overall quality of life. Emotional, spiritual, financial, physical preparation and acceptance can be very stressful for the patient [17-19]. Counseling plays an important role in understanding the consequences of this terminal disease.

Several modalities such as chest x-ray, computed tomography (CT) scan, sputum cytology, needle biopsy, bronchoscopy, and mediastinoscopy are available to clinicians to confirm the diagnosis and the type of cancer [20]. However, because of the nature of the disease, invasiveness of the diagnostic tests, or the time and expenses involved, some patients may refuse further intervention.

The type of lung cancer is named depending on the specific location where it is thought to arise. Histologic examination is required for the primary tumor classification while special immunohistochemical staining is done to further distinguish among the different subtypes of lung carcinoma. Several molecular biomarkers can also be tested when possible mutations exist. The 2 major types of lung cancer are non-small cell and small cell lung cancer. Small cell carcinoma accounts for about 20% of cases while non-small cell carcinoma comprises 80% of lung malignancy [21-22].

The stage of lung cancer illustrates the behavior of the tumor including its size, location, invasion of lymph nodes and the spread to the distant organs of the body that affects its function. Detecting lung cancer at an early stage before it invades surrounding tissues will lead to a decrease in morbidity and mortality. Knowing the stage of the disease will guide the decision-making process with regard to choosing the type of treatment and predict the chances of survival after therapy [23].

2MONOGRAPH ON LUNG CANCER: LUNG CANCER REGISTRY DATA OF 2000–2008 Lung Center of the Philippines

Treatment includes basic supportive care, resective surgery, radiotherapy, chemotherapy and palliation, with the purpose of prolonging and improving quality of life and provide potential cure after diagnosis [5, 24, 25]. Caring for diagnosed cases depends on the individual’s health status prior to giving of any pharmacologic agents with inherent variable toxicities. Monitoring for the response to therapy requires constant examination for possible medical complications. Common reasons for admission may be associated with the original location of the tumor or metastasis to other organs, treatment-related adverse effects or the presenting co-morbidities. Since accuracy and consistency of care is of importance, a regular follow-up of the patient should be established. It will also help the clinicians to keep track of the patient’s survival status.


OB

JEC

TIV

ES

General Objective

To present the summary statistics of lung cancer data at the Lung Center of the Philippines for the period 2000-2008.

Specific Objectives

1. To describe the demographic characteristics of lung cancer patients

2. To describe patients’ lung cancer information

3. To define the determinants of lung cancer mortality


MET

HO

DO

LOG

Y Data Collection and Forms Used

The data were extracted from the medical records of lung cancer patients admitted at the Lung Center of the Philippines (LCP) from 2000 to 2008 and recorded in the Lung Cancer Registry forms. Included were patients who had a histologic diagnosis of small cell carcinoma, non-small cell carcinoma and any of its sub-types, and those with cytologic findings of malignant cells from specimen taken from the lungs and respiratory samples, including pleural fluid. Excluded were patients with metastatic lung disease from non-lung primary, those with lung masses not subjected to diagnostic work-up and those with incomplete information regarding imaging or staging procedures.

Data extraction from the medical records was performed and recorded in Lung Cancer Registry data collection forms. The data included in the registry are shown in Appendix 1 – Lung Cancer Registry Form (LCP Form No. 62-001); Appendix 2 – Lung Cancer Registry (Follow-up/Re-admission Form) (LCP Form No. 62-013); and Appendix 3 – Lung Cancer Registry (Management Form) (LCP Form No. 63-003). For the first admission, data were recorded in Form No. 62-001 and Form No. 63-003. The data of the succeeding admission/s, if any, were recorded in the Form No. 62-013 and Form No. 63-003. The initial drafts of the forms were submitted for review to the LCP Tumor Board and then finalized by the authors.

Records were reviewed for deaths occurring in the hospital anytime between 2000 and 2011. For patients who were discharged alive during their last admission to LCP, their vital status as of December 2011 were verified through telephone calls to the last known contact number of the patient, or through request for information from their attending physicians. For those without information, verification of deaths were obtained through official communication and coordination with the National Statistics Office.

Data Encoding, Validation and Cleaning

The data recorded in the Lung Cancer Registry data collection forms were encoded using the EPI INFO data entry program prepared by the LCP Department of Research and Department.

To ensure the quality of data, a system of double-encoding, data validation and cleaning were implemented. For double-encoding, 2 data sets were entered independently by separate encoders. The dataset obtained in the first encoding was compared with the second encoding. All the discrepancies were validated in the extraction forms. Validation was performed by comparing the encoded data with the data in the extraction forms for a sample of patient records. Data cleaning was done to check for missing data, inconsistencies in the data and plausibility of the data. These were done through discussions during periodic meetings of the Lung Cancer Registry group.

Data Analysis

After ensuring the quality of data, the lung cancer data were analyzed using the STATA 12 software. Frequency and percentage distribution were obtained for the qualitative data (categorical data) while the means and standard deviations were calculated for the quantitative data. The information were summarized and presented in tables and graphs.


RES

ULT

S The medical records of 3,950 lung cancer patients admitted at the Lung Center of the Philippines from year 2000 to 2008 were collected and reviewed.

A. Demographic Profile

There were more males than females in the study population, who accounted for more than 70% of cases every year from 2000 to 2008. There was an increasing trend in the number of cases seen during the said period (see Table A1).

Table A1. Frequency and percentage distribution of incident casesaccording to patient’s sex and year of first hospital admission

SexYear of first admission

2000 2001 2002 2003 2004 2005 2006 2007 2008 Total

Male 193(78.8)

194(74.6)

277(72.5)

334(80.1)

367(71.3)

315(67.5)

401(72.9)

399(71.3)

390(70.4)

2,870(72.7)

Female 52 (21.2)

66(25.4)

105(27.5)

83(19.9)

148(28.7)

152(32.6)

149(27.1)

161(28.7)

164(29.6)

1,080(27.3)

Total 245(100.0)

260(100.0)

382(100.0)

417(100.0)

515(100.0)

467(100.0)

550(100.0)

560(100.0)

554(100.0)

3,950(100.0)

More than 50% of lung cancer cases occurred from the 6th decade of life onwards. However, cases of lung cancer patients was noted to increase beginning age 40 years, with the mean age recorded at 60.5 years old (SD=11.1). Only 4% of cases occurred before the age of 40 years (see Table A2).

Table A2. Frequency and percentage distribution of incident casesaccording to patient’s age and year of first hospital admission

Age group(year)

Year of first admission

2000 2001 2002 2003 2004 2005 2006 2007 2008 Total

<39 11(4.5)

15(5.8)

13(3.4)

16(3.8)

26(5.1)

16(3.4)

23(4.2)

20(3.6)

21(3.8)

161(4.1)

40–59 107(43.7)

111(42.7)

166(43.5)

186(44.6)

200(38.8)

198(42.4)

212(38.6)

234(41.8)

214(38.6)

1,628(41.2)

>60 127(51.8)

134(51.5)

203(53.1)

215(51.6)

289(56.1)

253(54.2)

315(57.3)

306(54.6)

319(57.6)

2,161(54.7)

Total 245(100.0)

260(100.0)

382(100.0)

417(100.0)

515(100.0)

467(100.0)

550(100.0)

560(100.0)

554(100.0)

3,950(100.0)

Table A3 shows that most of the lung cancer patients were males who were 60 years old and above (40.9%). It can also be seen that in both sexes, the number of lung cancer patients increases as age group increases. It can also be noted that females account for just 25 to 29% of the lung cancer cases among patients 40 years and above, but they accounted for 40% of patients less than 40 years of age.


More than 90% of the cases were either married or widowed (see Table A4). There is no evidence that marital status per se increases lung cancer risk. The percentage may just reflect the age range of the majority of the cohort, which are more likely to be married as age increases.

Table A3. Frequency and percentage distribution of incident cases according to patient’s sex and age

SexAge group

<39 40–59 >60 Total

Male 95(2.4)

1,159(29.3)

1,616(40.9)

2,870(72.7)

Female 66(1.7)

469(11.9)

545(13.8)

1,080(27.3)

Total 161(4.1)

1,628(41.2)

2,161(54.7)

3,950(100.0)

Table A4. Frequency and percentage distribution of incident casesaccording to patient’s civil status and year of first hospital admission

Civil Status

Year of first admission2000 2001 2002 2003 2004 2005 2006 2007 2008 Total

Married 198(80.8)

212(81.5)

314(82.2)

347(83.2)

401(77.9)

372(79.7)

454(82.6)

441(78.8)

418(75.5)

3,157(79.9)

Widowed 31(12.7)

24(9.2)

40(10.5)

45(10.8)

72(14.0)

66(14.1)

56(10.2)

83(14.8)

91(16.4)

508(12.9)

Single 9(3.7)

20(7.7)

18(4.7)

15(3.6)

30(5.8)

22(4.7)

30(5.5)

27(4.8)

34(6.1)

205(5.2)

Separated 7(2.9)

3(1.2)

6(1.6)

7(1.7)

9(1.8)

6(1.3)

7(1.3)

8(1.4)

9(1.6)

62(1.6)

Not known

0(0.0)

1(0.4)

4(1.1)

3(0.7)

3(0.6)

1(0.2)

3(0.6)

1(0.2)

2(0.4)

18(0.5)

Total 245(100.0)

260(100.0)

382(100.0)

417(100.0)

515(100.0)

467(100.0)

550(100.0)

560(100.0)

554(100.0)

3,950(100.0)

Table A5 shows that the National Capital Region (NCR) accounted for around 43% of lung cancer patients every year. The other 40% came from the nearby Regions III and IVA. This reflects the main catchment area of the Lung Center of the Philippines which is located in Quezon City, in the National Capital Region.

Table A6 shows that a large number of the lung cancer patients have “special occupations”. Special occupations include non-gainful occupations such as housewife, pensioner and retired employee. The next big group of patients were farmers, forestry workers and fishermen, followed by plant and machine operators and assemblers. Although lung cancer is associated with certain occupational exposures, there seems to be no predilection for any profession or occupation in this cohort.


Tabl

e A

5. F

requ

ency

and

per

cent

age

dist

ribut

ion

of in

cide

nt c

ases

acc

ordi

ng to

per

man

ent a

ddre

ss (r

egio

n) a

nd y

ear o

f firs

t hos

pita

l adm

issi

on

Reg

ion

Year

of fi

rst a

dmis

sion

2000

2001

2002

2003

2004

2005

2006

2007

2008

Tota

l

I8

(3.3

)10 (3.9

)24 (6.3

)32 (7.7

)22 (4.3

)16 (3.4

)24 (4.4

)11 (2.0

)11 (2.0

)15

8(4

.0)

II15 (6.1

)7

(2.7

)9

(2.4

)21 (5.0

)18 (3.5

)14 (3.0

)17 (3.1

)13 (2.3

)11 (2.0

)12

5(3

.2)

III64

(26.

1)57

(21.

9)95

(24.

9)99

(23.

7)93

(18.

1)11

2(2

4.0)

114

(20.

7)12

5(2

2.3)

118

(21.

3)87

7(2

2.2)

IVA

45(1

8.4)

41(1

5.8)

56(1

4.7)

64(1

5.4)

104

(20.

2)91

(19.

5)10

7(1

9.5)

119

(21.

3)11

1(2

0.0)

738

(18.

7)

IVB

6(2

.5)

3(1

.2)

10 (2.6

)8

(1.9

)14 (2.7

)9

(1.9

)13 (2.4

)6

(1.1

)8

(1.4

)77 (2.0

)

V2

(0.8

)12 (4.6

)5

(1.3

)8

(1.9

)9

(1.8

)7

(1.5

)10 (1.8

)11 (2.0

)8

(1.4

)72 (1.8

)

VI

1(0

.4)

2(0

.8)

3(0

.8)

2(0

.5)

3(0

.6)

0(0

.0)

6(1

.1)

4(0

.7)

3(0

.5)

24 (0.6

)

VII

0(0

.0)

2(0

.8)

1(0

.3)

0(0

.0)

1(0

.2)

2(0

.4)

1(0

.2)

1(0

.2)

0(0

.0)

8(0

.2)

VIII

1(0

.4)

2(0

.8)

5(1

.3)

3(0

.7)

8(1

.55)

9(1

.9)

6(1

.1)

10 (1.8

)10 (1.8

)54 (1.4

)

IX0

(0.0

)0

(0.0

)1

(0.3

)1

(0.2

)3

(0.6

)0

(0.0

)1

(0.2

)3

(0.5

)0

(0.0

)9

(0.2

)

X0

(0.0

)1

(0.4

)1

(0.3

)0

(0.0

)3

(0.6

)3

(0.6

)0

(0.0

)0

(0.0

)1

(0.2

)9

(0.2

)

XI

0(0

.0)

0(0

.0)

0(0

.0)

0(0

.0)

0(0

.0)

1(0

.2)

0(0

.0)

0(0

.0)

0(0

.0)

1(0

.0)

XII

0(0

.0)

0(0

.0)

4(1

.1)

2(0

.5)

2(0

.4)

1(0

.2)

0(0

.0)

0(0

.0)

0(0

.0)

9(0

.2)

CA

RA

GA

0(0

.0)

0(0

.0)

1(0

.3)

1(0

.2)

2(0

.4)

2(0

.4)

2(0

.4)

0(0

.0)

0(0

.0)

8(0

.2)

CA

R3

(1.2

)1

(0.4

)1

(0.3

)1

(0.2

)2

(0.4

)2

(0.4

)3

(0.6

)3

(0.5

)2

(0.4

)18 (0.5

)

AR

MM

0(0

.0)

0(0

.0)

1(0

.3)

0(0

.0)

0(0

.0)

1(0

.2)

0(0

.0)

1(0

.2)

2(0

.4)

5(0

.1)

NC

R95

(38.

9)11

7(4

5.0)

155

(40.

6)17

0(4

0.8)

215

(41.

8)19

3(4

1.3)

240

(43.

6)24

8(4

4.3)

264

(47.

7)1,

697

(43.

0)

CA

NN

OT

BE

D

ETE

RM

INE

D4

(1.6

)4

(1.5

)9

(2.4

)5

(1.2

)9

(1.8

)2

(0.4

)2

(0.4

)2

(0.4

)3

(0.5

)40 (1.0

)

NO

INFO

RM

ATIO

N1

(0.4

)1

(0.4

)1

(0.3

)0

(0.0

)7

(1.4

)2

(0.4

)4

(0.7

)3

(0.5

)2

(0.4

)21 (0.5

)

Tota

l24

5(1

00.0

)26

0(1

00.0

)38

2(1

00.0

)41

7(1

00.0

)51

5(1

00.0

)46

7(1

00.0

)55

0(1

00.0

)56

0(1

00.0

)55

4(1

00.0

)3,

950

(100

.0)


Tabl

e A

6. F

requ

ency

dis

tribu

tion

of in

cide

nt c

ases

acc

ordi

ng to

pat

ient

’s o

ccup

atio

n an

d ye

ar o

f firs

t hos

pita

l adm

issi

on

Maj

or g

roup

s of

occ

upat

iona

Year

of a

dmis

sion

2000

2001

2002

2003

2004

2005

2006

2007

2008

Tota

lS

peci

al o

ccup

atio

ns74

6511

511

117

516

114

415

821

11,

214

Offi

cial

s of

gov

ernm

ent a

nd s

peci

al in

tere

st

orga

niza

tions

, cor

pora

te e

xecu

tives

, man

ager

s,

man

agin

g pr

oprie

tors

and

sup

ervi

sors

67

1110

1910

2725

2013

5

Pro

fess

iona

ls13

1011

1020

248

3127

154

Tech

nici

ans

and

asso

ciat

e pr

ofes

sion

als

33

25

84

96

444

Cle

rks

12

21

23

24

118

Ser

vice

wor

kers

and

sho

p an

d m

arke

t sal

es

wor

kers

67

1111

1514

912

1710

2

Farm

ers,

fore

stry

wor

kers

and

fish

erm

en51

5357

6480

6665

7159

566

Trad

es a

nd re

late

d w

orke

rs11

1718

2439

2917

3522

212

Pla

nt a

nd m

achi

ne o

pera

tors

and

ass

embl

ers

1717

4032

4136

4337

4931

2

Labo

rers

and

uns

kille

d w

orke

rs8

910

1622

1217

2025

139

Oth

ers:

Ove

rsea

s Fi

lipin

o W

orke

rs (O

FW)

10

23

15

31

521

Can

not b

e de

term

ined

12

12

55

77

333

Sel

f-em

ploy

ed2

34

23

04

54

27

Fact

ory

wor

ker

03

24

14

45

427

Gov

ernm

ent E

mpl

oyee

104

716

117

1314

688

Em

ploy

ee1

55

45

1311

1014

68

No

info

rmat

ion

4053

8410

268

7416

711

983

790

Tota

l24

526

038

241

751

546

755

056

055

43,

950

a Th

e co

llect

ed in

form

atio

n on

occ

upat

ion

was

cod

ed a

nd g

roup

ed u

sing

the

Phi

lippi

ne S

tand

ard

Occ

upat

iona

l and

Cla

ssifi

catio

n of

200

7 (P

SO

C 2

007)

.


B. Medical, Social, and Family History

A history of smoking was present in a large majority of the lung cancer cases, with only 24% of cases recorded as lifetime non-smokers. Likewise, a history of variable amounts of alcohol intake was noted in large percentage of patients (Table B1). Alcohol consumption was prevalent among the lung cancer cases and only 27.4% of cases denied any alcohol consumption. However, in 19.5% of cases no data on alcohol intake was available (Table B2).

Table B1. Frequency and percentage distribution of incident casesaccording to patient’s smoking status and year of first hospital admission

Smoking Status

Year of first admission2000 2001 2002 2003 2004 2005 2006 2007 2008 Total

Smoker 118(48.2)

130(50.0)

201(52.6)

260(62.4)

235(45.6)

239(51.2)

279(50.7)

315(56.3)

291(52.5)

2,068(52.4)

Occasional smoker

3(1.2)

1(0.4)

0(0.0)

0(0.0)

4(0.8)

5(1.1)

1(0.2)

3(0.5)

2(0.4)

19(0.5)

Ex-smoker 84(34.3)

71(27.3)

87(22.8)

81(19.4)

144(28.0)

88(18.8)

128(23.3)

84(15.0)

100(18.1)

867(22.0)

Non-smoker 39(15.9)

57(21.9)

87(22.8)

73(17.5)

127(24.7)

130(27.8)

128(23.3)

147(26.3)

157(28.3)

945(23.9)

Not known 1(0.4)

1(0.4)

7(1.8)

3(0.7)

5(1.0)

5(1.1)

14(2.6)

11(2.0)

4(0.7)

51(1.3)

Total 245(100.0)

260(100.0)

382(100.0)

417(100.0)

515(100.0)

467(100.0)

550(100.0)

560(100.0)

554(100.0)

3,950(100.0)

Table B2. Frequency and percentage distribution of incident casesaccording to patient’s alcohol intake and year of first hospital admission

Alcohol intake Status

Year of first admission

2000 2001 2002 2003 2004 2005 2006 2007 2008 Total

Alcoholic 32(13.1)

51(19.6)

62(16.2)

68(16.3)

79(15.3)

57(12.2)

101(18.4)

101(18.0)

109(19.7)

660(16.7)

Occasional Drinker

76(31.0)

71(27.3)

94(24.6)

116(27.8)

147(28.5)

132(28.3)

151(27.5)

182(32.5)

174(31.4)

1,143(28.9)

Previous Alcoholic

25(10.2)

32(12.3)

25(6.5)

37(8.9)

37(7.2)

37(7.9)

35(6.4)

37(6.6)

29(5.2)

294(7.4)

Non-alcoholic 52(21.2)

73(28.1)

98(25.7)

94(22.4)

122(23.7)

157(33.6)

141(25.6)

161(28.8)

186(33.6)

1,084(27.4)

Not known 60(24.5)

33(12.7)

103(27.0)

102(24.5)

130(25.2)

84(18.0)

122(22.2)

79(14.1)

56(10.1)

769(19.5)

Total 245(100.0)

260(100.0)

382(100.0)

417(100.0)

515(100.0)

467(100.0)

550(100.0)

560(100.0)

554(100.0)

3,950(100.0)

A significant number of lung cancer cases had history of previous or pre-existing lung diseases, including PTB (28.7%), COPD (12%), pneumonia (10%) and asthma (2%). Hypertension was present in 17% of the cases (Table B3).


Table B3. Frequency distribution of co-existing illnesses amonglung cancer patients during their first hospital admission

Co-morbidityYear of first admission

2000 2001 2002 2003 2004 2005 2006 2007 2008 TotalPneumonia 22 21 26 38 53 52 46 65 87 410

Cardiac Disease 17 18 19 18 28 33 48 49 40 270

PTB 73 68 110 111 144 123 145 183 178 1135

COPD 27 31 35 33 51 53 82 80 84 476

Diabetes 13 16 24 35 52 53 61 68 64 386

Hypertension 25 35 44 50 85 80 121 116 126 682)

Asthma 2 3 4 4 8 8 12 23 17 81

Allergy 13 9 13 14 16 26 19 30 31 171

Anemia 1 5 18 30 13 5 26 13 5 116

Bleeding tendencies 2 0 1 0 1 2 1 0 0 7

AIDS 0 0 0 0 0 0 0 0 0 0

Malignancy 1 1 3 1 3 4 3 4 1 21

Others 10 12 16 19 21 13 34 29 25 179

No information 18 13 31 15 27 27 40 23 12 206

No co-existing disease 90 112 146 165 187 150 167 168 162 1,347

Table B4. Frequency distribution of medical conditions in the patient’s family historyaccording to year of first hospital admission

Medical ConditionYear of first admission

2000 2001 2002 2003 2004 2005 2006 2007 2008 TotalPTB 44 68 66 95 113 85 95 137 122 825

Cardiac Disease 22 40 42 45 69 58 64 60 103 503

AIDS 0 0 0 0 0 0 1 0 0 1

Diabetes 35 45 40 69 84 80 96 112 131 692

Hypertension 69 84 97 124 139 154 189 230 238 1,324

Asthma 46 46 61 71 97 87 87 123 138 756

Allergy 11 10 17 19 25 24 25 21 37 189

Anemia 4 1 9 14 7 9 8 13 17 82

Bleeding tendencies 3 2 6 3 6 6 5 1 1 33

Malignancy 48 65 58 86 132 124 146 147 168 974

Others 0 2 3 3 1 1 7 7 10 34

No information 15 19 47 21 44 43 63 40 27 319

No history of illness 89 62 143 136 148 130 152 115 107 1,082

A family history of malignancy was present in 25% of the cases. PTB and asthma in the family were reported in 21% and 19% of cases, respectively. Hypertension was present in the family in 34% and diabetes mellitus in 18% (Table B4).


C. Clinical Information on Admission

Table C1 shows that the majority (87%) of lung cancer patients have non-small cell carcinoma (NSCLC) while 10% were due to small cell carcinoma. Among the cases of non-small cell carcinoma, adenocarcinoma was the predominant sub-type (48%), while squamous cell carcinoma accounted for 20%. However, it should be pointed out that there was a large percentage of cases (30%) wherein histopathologic examination failed to identify the specific sub-type of NSCLC. These cases would require further tests like immunohistochemical staining to determine whether they are adenocarcinoma or squamous cell carcinoma.

Table C1. Frequency and percentage distribution of incident cases according tohistological classification of lung cancer and year of first hospital admission

HistopathologyYear of Notification

2000 2001 2002 2003 2004 2005 2006 2007 2008 TotalNon-small cell

carcinoma213 228 330 355 444 415 487 492 475 3,439

(87.1)

AdenocarcinomaUnspecifiedSquamousLarge CellAdenosquamousOthers

895861

401

1126846

110

1439578

860

1829276

320

22911495

420

21011985

100

241147

94140

212189

80722

230151

86242

1,6481,033

7013121

5

Small Cell Carcinoma 29 30 42 55 58 45 44 44 60 407(10.3)

Unspecified cell type 1 0 3 0 3 1 2 5 8 23(0.6)

Malignant cell 2 2 7 7 10 6 17 19 11 81(2.0)

Total 245 260 382 417 515 467 550 560 554 3,950(100)

WHO Histological Classification of Tumours of the Lung, 2004

At the time of diagnosis, more than half of the NSCLC cases were already at Stage IV disease (Stage IV-a=42.2%; Stage IV-b=16.6%). Only 7.5% of cases were diagnosed in Stage I and 4.8% in Stage II (Table C2). For small cell carcinoma cases, 237 of 407 (58%) were at the extensive stage at time of diagnosis.


Tabl

e C

2. F

requ

ency

and

per

cent

age

dist

ribut

ion

of in

cide

nt c

ases

acc

ordi

ng to

lung

can

cer s

tage

and

year

of fi

rst h

ospi

tal a

dmis

sion

Stag

eN

otifi

catio

n ye

ar /

Year

of fi

rst h

ospi

tal /

Lun

g ca

ncer

regi

stra

tion

2000

2001

2002

2003

2004

2005

2006

2007

2008

Tota

lN

on-s

mal

l cel

l car

cino

ma

IA1

(0.4

)1

(0.4

)3

(0.8

)0

(0.0

)4

(0.8

)0

(0.0

)2

(0.4

)2

(0.4

)2

(0.4

)15 (0.4

)

IB16 (6.5

)21 (8.1

)27 (7.1

)28 (6.7

)31 (6.0

)36 (7.7

)32 (5.8

)53 (9.5

)37 (6.7

)28

1(7

.1)

IIA0

(0.0

)0

(0.0

)0

(0.0

)0

(0.0

)1

(0.2

)0

(0.0

)0

(0.0

)1

(0.2

)0

(0.0

)2

(0.1

)

IIB15 (6.1

)6

(2.3

)11 (2.9

)19 (4.6

)21 (4.1

)26 (5.6

)25 (4.5

)15 (2.7

)12 (2.2

)15

0(3

.8)

IIIA

33(1

3.5)

30(1

1.5)

43(1

1.3)

44(1

0.6)

53(1

0.3)

39 (8.4

)52 (9.5

)48 (8.6

)49 (8.8

)39

1(9

.9)

IIIB

27(1

1.0)

33(1

2.7)

30 (7.9

)25 (6.0

)41 (8.0

)36 (7.7

)25 (4.5

)21 (3.8

)26 (4.7

)26

4(6

.7)

IVA

75(3

0.6)

104

(40.

0)14

4(3

7.7)

166

(39.

8)21

1(4

1.0)

196

(42.

0)25

8(4

6.9)

255

(45.

5)25

9(4

6.8)

1,66

8(4

2.2)

IVB

46(1

8.8)

33(1

2.7)

72(1

8.8)

73(1

7.5)

79(1

5.3)

80(1

7.1)

91(1

6.5)

96(1

7.1)

84(1

5.2)

654

(16.

6)

Not

kno

wn

0(0

.0)

0(0

.0)

0(0

.0)

0(0

.0)

3(0

.6)

2(0

.4)

2(0

.4)

1(0

.2)

6(1

.1)

14 (0.4

)

Sub

tota

l21

322

833

035

544

441

548

749

247

53,

439

Sm

all C

ell C

arci

nom

a

Lim

ited

16 (6.5

)15 (5.8

)24 (6.3

)19 (4.6

)27 (5.2

)15 (3.2

)16 (2.9

)16 (2.9

)21 (3.8

)16

9(4

.3)

Ext

ensi

ve12 (4.9

)15 (5.8

)18 (4.7

)36 (8.6

)31 (6.0

)30 (6.4

)28 (5.1

)28 (5.0

)39 (7.0

)23

7(6

.0)

Not

kno

wn

1(0

.4)

0(0

.0)

0(0

.0)

0(0

.0)

0(0

.0)

0(0

.0)

0(0

.0)

0(0

.0)

0(0

.0)

1(0

.0)

Sub

tota

l29

3042

5558

4544

4460

407

Can

not b

e st

aged

3(1

.2)

2(0

.8)

10 (2.6

)7

(1.7

)13 (2.5

)7

(1.5

)19 (3.5

)24 (4.3

)19 (3.4

)10

4(2

.6)

Gra

nd T

otal

245

(100

.0)

260

(100

.0)

382

(100

.0)

417

(100

.0)

515

(100

.0)

467

(100

.0)

550

(100

.0)

560

(100

.0)

554

(100

.0)

3,95

0(1

00.0

)

Uni

on fo

r Int

erna

tiona

l Can

cer C

ontro

l TN

M C

lass

ifica

tion

of M

alig

nant

Tum

ours

, 7th

edi

tion


Table D1. Frequency and percentage distribution of incident cases according to genderand histological classification of lung cancer

SexHistopathology

Non-small cell carcinoma

Small Cell Carcinoma

Unspecified cell type Malignant cell Total

Female 1,008(25.5)

50(1.3)

3(0.1)

19(0.5)

1,080(27.3)

Male 2,431(61.5)

357(9.0)

20(0.5)

62(1.6)

2,870(72.7)

Total 3,439(87.1)

407(10.3)

23(0.6)

81(2.1)

3,950(100.0)

Table D2. Frequency and percentage distribution of non-small cell lung cancer cases according to sexand cell type

SexNon-small Cell Lung Cancer

Adeno-carcinoma Unspecified Squamous Large Cell Adeno-

squamous Others Total

Female 645(18.8)

259(7.5)

90(2.6)

7(0.2)

5(0.1)

2(0.1)

1,008(29.3)

Male 1,003(29.1)

774(22.5)

611(17.8)

24(0.7)

16(0.5)

3(0.1)

2,431(70.7)

Total 1,648(47.9)

1,033(30.0)

701(20.4)

31(0.9)

21(0.6)

5(0.2)

3,439(100.0)

D. Histopathologic Classification

The distribution of cancer types and subtypes according to gender is seen in Tables D1 and D2. Although males outnumber females in all lung cancer cell types or subtypes, among females, it is notable that adenocarcinoma subtype far outnumbered the squamous subtype.


Table E2. Frequency distribution of management options availedaccording to histological classification of lung cancer

ManagementHistopathology

Non-small cell carcinoma

Small Cell Carcinoma

Unspecified cell type Malignant cell Total

Diagnostic procedure 2,728 329 2 64 3,123

Supportive Care 840 98 15 29 982

Surgery 155 1 0 1 157

Chemotherapy 854 154 1 2 1,011

Radiotherapy 459 88 3 5 555

Palliative care 1,045 92 1 21 1,159

Table E1. Frequency distribution of management optionsavailed on patient’s first admission

ManagementYear of first admission

2000 2001 2002 2003 2004 2005 2006 2007 2008 Total (%)

Diagnostic procedure 211 218 317 325 394 376 409 444 429 3,123

(79.1)

Supportive Care 39 39 62 97 249 89 160 117 130 982

(24.9)

Surgery 13 9 21 20 21 17 21 13 22 157(4.0)

Chemotherapy 58 59 102 101 146 124 161 135 125 1,011(25.6)

Radiotherapy 57 49 71 63 76 51 80 54 54 555(14.1)

Palliative care 51 67 95 135 141 148 159 181 182 1,159(29.3)

Study population: 3950 cases

E. Medical Management

Nearly 80% underwent diagnostic and staging procedures at the Lung Center. Due to the advanced stage of the disease, the most frequent therapeutic management consisted of palliative therapy (29.3%), chemotherapy (25.6%) and supportive care (25.0%). Only 157 or 4.0% underwent definitive surgery as management of lung cancer (Table E1). The percentages of management received were consistent across type (non-small cell vs. small cell) and sub-type of lung cancer (adenocarcinoma versus squamous cell carcinoma) (Table E2).

Table E3 shows that in terms of non-small cell lung cancer (NSCLC), surgery was more frequently performed for lung cancer stages IIIA and below compared to advanced stages. On the other hand, chemotherapy, radiotherapy and palliative care were options usually performed for NSCLC stages IIIB and above. For small cell lung cancer (SCLC), only 1 patient had surgery. Chemotherapy and radiotherapy were given at the same frequency for both limited and extensive stages of small cell CA. However, supportive care and palliative care were more frequently provided to patients with extensive disease.


Tabl

e E

3. F

requ

ency

dis

tribu

tion

of in

cide

nt c

ases

acc

ordi

ng to

lung

can

cer s

tage

and

man

agem

ent o

ptio

ns a

vaile

d on

adm

issi

on

Stag

eM

anag

emen

tD

iagn

ostic

pro

cedu

reSu

ppor

tive

Car

eSu

rger

yC

hem

othe

rapy

Rad

ioth

erap

yPa

lliat

ive

care

Non

-sm

all c

ell c

arci

nom

a

IA14

77

20

0

IB27

541

5941

2422

IIA1

10

00

0

IIB14

128

3128

1911

IIIA

329

7738

144

9426

IIIB

229

570

9661

16

IVA

1245

440

1537

916

182

7

IVB

494

184

515

598

142

Not

kno

wn

05

09

21

Tota

l27

2884

015

585

445

910

45

Sm

all C

ell C

arci

nom

a

Lim

ited

145

281

7746

5

Ext

ensi

ve18

370

077

4287

Not

kno

wn

10

00

00

Tota

l32

998

115

488

92

Can

not b

e st

aged

6644

13

822


F. Vital Status

The vital status of lung cancer patients are shown in the following graphs according to gender (Figure F1), according to age (Figure F2), according to smoking status (Figure F3) and to alcohol consumption (Figure F4). Mortality rates of around 70% were seen in all patients regardless of the above variables.

Male: 2073/2870=72.2%, Female: 779/1080=72.1%

Figure F1. Frequency distribution of patient’s vital status according to sex (as of December 31, 2011)

Figure F2. Frequency distribution of patient’s vital status according to age group (as of December 31, 2011)

Dead: < 39: 75.8%; 40-59: 71.4%; >60: 72.6%


Figure F3. Frequency distribution of patient’s vital status according to smoking status(as of December 31, 2011)

Figure F4. Frequency distribution of patient’s vital status according to alcohol intake status(as of December 31, 2011)


Figure F5. Frequency distribution of patient’s vital status according to lung cancer histopathology(as of December 31, 2011)

Figure F6. Frequency distribution of patient’s vital status according to lung cancer stage at notification

Comparison of death rates by gender showed no difference: males: 72.2% vs. females 72.1%.

Figure F5 shows survival rates according to histopathologic classification and Figure 6a by clinical staging.


Table F1. Life table of lung cancer patients at different time intervals for all cell types

Time Interval

Number of subjects

at the beginning

Number of deaths Lost Survival

ProbabilityStandard

Error

[95%Confidence

Interval]

0-31 days(0-1 month) 3950 701 791 0.8028 0.0067 [0.7893, 0.8155]

31-90 days(1-3 months) 2458 691 127 0.5711 0.0088 [0.5536, 0.5882]

90-180 days(3-6 months) 1640 483 84 0.3985 0.0090 [0.3808, 0.4161]

180-365 days(6mos-1 yr) 1073 483 61 0.2139 0.0078 [0.1987, 0.2294]

365-1095 days(1-3 years) 529 393 25 0.0511 0.0044 [0.0429, 0.0603]

1095-1825 days(3-5 years) 111 59 8 0.0229 0.0032 [0.0173, 0.0298]

1825-3650 days(5-10 years) 44 40 2 0.0016 0.009 [0.0005, 0.0045]

3650 days-onwards(10 years onwards) 2 2 0 0.0000 – –

The life table (Table F1) shows an 80% probability of survival during the first month after diagnosis, and around 60% survival during the succeeding 2 months and then goes down to 40% from the 4th to the 6th month. The probability of survival is 21% from the 7th to the 12th month. Thereafter, the probability of survival becomes very low at <5%.


SUM

MA

RY

Lung cancer is most common in male smokers 60 years or more. Lung cancer increases with age but is uncommon in persons less than 40 years. Males outnumber females in all age groups, but females account for a larger percentage (40%) of the cases less than 40 years old than in older age groups (25 to 29%). This is consistent with recent international trends which still show that lung cancers are more common in men although rates in females had been rising, and differences in sexes had been narrowing (21).

Married persons make up 80% of the lung cancer patients but there is no indication that marital status presents with a particular risk for lung cancer, and this finding may just reflect the older age of the cohort which is more likely to be married than not. Most of the cases in this cohort come from the National Capital Region, and the adjacent Central Luzon and Southern Tagalog regions, reflecting the main catchment areas of the institution. The lung cancer cases in this cohort come from all types of professions and occupations, with no particular predilection. While lung cancer may be associated with certain occupational exposures, this was not evident in this group.

The majority of cases were smokers. This shows that smoking is still the primary risk factor for lung cancer and underscores the need for greater efforts to reduce smoking prevalence in the general population. Tobacco control programs should be pursued vigorously since these have been associated with a decline in smoking rates and subsequent lung cancer incidence rates [26-27]. Renewed cessation and prevention efforts should be expanded and intensified to curb prevalence of cigarette smoking and to reduce lung cancer rates eventually (21). However, a significant percentage or nearly a quarter were not related to smoking. The reasons for the development of lung cancer in this segment should be further studied.

Alcohol intake in varying degrees was present in less than 50%. Pooled analysis of 7 prospective studies with 399,767 participants and 3137 lung cancer cases show a slightly greater risk of lung cancer among people who consumed at least 30gram of alcohol per day compared to those who abstained from alcohol (28).

Pulmonary tuberculosis is a commonly associated condition with lung cancer in this cohort. Pneumonia and COPD are also frequently associated with lung cancer. Patients with lung cancer may develop active pulmonary TB; or there could be the occurrence of cancer in patients treated for pulmonary TB. Chronic inflammation due to TB is thought to be responsible for the genesis of cancer. Co-existence of cancer and TB often causes a delay in the diagnosis. Patients with cancer are vulnerable to develop active TB because of immunosuppression due to malnutrition, or due to the use of intensive treatment modalities, such as aggressive chemotherapy [29].

In a population-based cohort study, Yu et al found that the incidence of lung cancers was approximately 11-fold higher in the cohort of patients with tuberculosis than nontuberculosis subjects (26.3 versus 2.41 per 10,000 person-years). Cox proportional hazard regression analysis showed a hazard ratio of 4.37 (95% confidence interval [CI]: 3.56–5.36) for the tuberculosis cohort after adjustment for the sociodemographic variables and 3.32 (95% CI: 2.70–4.09) after further adjustment for chronic obstructive pulmonary disease (COPD), smoking-related cancers (other than lung cancer), etc. The hazard ratio increased to 6.22 (95% CI: 4.87–7.94) with the combined effect of COPD and to 15.5 (95% CI: 2.17–110) with the combined effect of other smoking-related cancers [30].


Family history of malignancy was present in 25% of cases, reflecting the role of genetic predisposition in the development of lung cancer [3-5].

The single most frequent histologic type of lung cancer in this cohort is adenocarcinoma, followed by squamous cell carcinoma. Small cell carcinoma accounts for only 10% of confirmed cases. The emerging predominance of adenocarcinoma in lung cancer rates have been attributed to changes in smoking habits and changes in the type of tobacco in cigarettes. With the switch from non-filtered to filtered cigarettes, the depth of inhalation had been altered. With unfiltered cigarettes, inhalation tend to be shallow with chemical carcinogen deposition centrally in bronchial area, giving rise to SCLC while smoke from filtered milder cigarettes may be more deeply inhaled, resulting in more peripheral deposition and giving rise to adenocarcinoma. The reduction in nicotine content also promoted deeper inhalation as smokers tend to compensate. Changes in cigarette composition reduced the yield of carcinogenic polycyclic aromatic hydrocarbons (PAH), inducers of squamous cell carcinoma, while increasing the yield of carcinogenic tobacco-specific N-nitrosamines (TSNAs), inducers of adenocarcinoma. There is also a greater incidence of adenocarcinoma than squamous cell carcinoma among former smokers [31-33].

In our cohort, not many lung cancer patients were seen and diagnosed at the hospital at an early stage of the disease and hence effective procedures to improve survival may not be feasible to perform. Instead basic supportive care or palliative care are often the main management strategy for these patients. Late diagnosis contributed greatly to the observed mortality rate. This is not much different in other studies, wherein more than 65% of cases present with locally advanced or metastatic disease [34].


REC

OM

MEN

DAT

ION

S More smoking cessation and prevention efforts should be pursued to curb prevalence of cigarette smoking and to reduce lung cancer rates eventually.

Programs that promote screening of high-risk groups and early detection of lung cancer should be implemented within the hospital. Low-dose CT scan has been recommended as a cost-effective screening procedure.

A national web-based lung cancer registry will be useful in keeping track of the management done to the patients and their vital status. Collaboration with NSO should also be sustained so that vital status of patients can be accurately determined.


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APP

END

ICES

Appendix 1Lung Cancer Registry Form (Front)

(LCP Form No. 62-001)


Appendix 1 (continued)Lung Cancer Registry Form (Back)



Appendix 2Lung Cancer Registry (Follow-up/Re-admission Form)



Appendix 3Lung Cancer Registry (Management Form)


monograph on lung cancer - lung center of the...

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